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Operational Plan 2016/17


Contents

Area of discussion Page ref

Material Changes to Draft Operating Plan 1

Introduction 2 - 3

2015/16 Integrated Performance Summary 4 - 5

Approach to Activity Planning 6

Approach to Quality Planning 7 - 8

Approach to Quality Improvement 9 - 11

Approach to Workforce Planning 12 - 15

Approach to Financial Planning 15 - 20

New Operating Model 21 - 22

The Five Year Forward View (FYFV) - Emerging STP 23 - 24

Remedial Action Plan (RAP) 25 - 26

Glossary

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Material Changes to Draft Operating Plan

Our final operating plan has been developed with the same spirit which pervades throughout our draft plan submitted earlier in the year which seeks to improve our service delivery to patients and against national performance targets by increasing capacity in line with demand and also benefit the health system as a whole as we plan to change the way in which we respond to patients, underpinned by a future new operating model. We will work in partnership with other health providers to deliver this plan, supporting the emerging Sustainability and Transformation Plans (STP).

Our plans will require significant investment and therefore, as we are currently in negotiation with our Commissioners in this regard, our plans remain contingent.

Consequently, we have not provided for the costs of delivering our Remedial Action Plan (RAP) or proposed new operating model within our financial plan which is presented on a ‘nothing changes’ premise.

Since submission of our draft plan the following have emerged which require noting:

An agency cap of £3m has been imposed which we are seeking to negotiate upwards to enable us to deliver the RAP;

Our Commissioners have not currently committed to providing their support in funding our proposed RAP; and

Our Commissioners have not currently committed to providing their support in funding our proposed new operating model.

We continue to engage with Commissioners and NHS Improvement (NHSI) to resolve these issues and are confident that, with agreed funding, we will be able to begin to transition to an improved operating model which is capable of meeting increasing demand and providing better patient carewhilst delivering against national performance targets.


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1. Introduction

We provide emergency, urgent and non-emergency care to a population of around 5.9m across the six counties of Bedfordshire, Hertfordshire, Essex, Norfolk, Suffolk and Cambridgeshire. This containsa diverse range of rural, coastal and urban areas. We have tailored our services to meet each community’s differing environmental, demographic and medical needs. With the support of more than 4,000 staff and 1,500 volunteers we deal with more than 2,600 emergency calls every day, and handle in excess of 460,000 non-emergency patient journeys each year.

Our services are commissioned by 19 Clinical Commissioning Groups (CCG) and within our region we have 17 System Resilience Groups (SRG). In addition to the SRGs we engage with one Urgent & Emergency Care Network (UECN) which has recently been established and are committed to the emerging Sustainability and Transformation Plans (STPs).

We are led by a new substantive Chief Executive, and have formed a new executive team which is looking to deliver tangible change for the delivery of sustainable improvements to patient care and performance over the short, medium and long term. Committed to meeting the requirements of the Five Year Forward View (FYFV), the Urgent & Emergency Care Review and the Clinical Models for Ambulance Services guidance we believe that our Trust’s strategic view and planned direction of travel is supportive of system wide change, reflecting the ambitions of the STPs currently under development.

We are proud of our quality and safety standards, reflected in some of the early feedback from an on-going CQC inspection. However as with many other healthcare providers, despite providing high quality care, we have struggled to match resources to ever increasing demand. Consequently, wehave developed a Remedial Action Plan (RAP) which will allow us to improve our performance against national targets whilst transitioning towards a re-engineered operating model to deliver greater benefits to patients and the wider health care system.

We believe that through collaboration with other healthcare providers and through transforming our own operational model, underpinned by delivery of our Remedial Action Plan (RAP), we will be able to reduce inappropriate conveyance and truly deliver right person, right place, right time patient care across the East of England which will support the emerging STPs.

We will require Commissioner support and investment in our RAP and new operating model. This will provide us with the opportunity to realise a steady improvement in quality of care and performancewhilst at the same time creating the required ‘space’ to significantly change our operating model over the next three years.

Acknowledging the significance and importance of healthcare providers working together we are mindful that STP discussions are still developing. It is our aspiration is to accelerate the transition of our services to the UECN model but have prepared this Operational Plan to reflect the currently known position for our Trust as based on a ‘Nothing Changes’ premise (until we have agreed funding for both our RAP and new operating model with the Commissioners). Our strategy and plans are aligned with the spirit of the STPs which is reflected within our RAP (paragraph 10) and our proposal for a new operating model (paragraph 8).

Recognising the pressures that we will continue to be under to deliver national performance standards in 2016/17 with exponential growth in red calls, changes to NHS Ambulance Quality Indicator (AQI) Guidance, hospital handover delays and the need to deliver our Student Ambulance Paramedic (SAP) programme, we firmly believe that we can be the best provider for coordinating integrated access to health and social care across the region, combining 999, 111 and GP Out Of Hours servicesbenefitting patients and the wider health system.

We will continue to discuss the benefits of our strategy and the transformation in services we can offer with our Commissioners and look for opportunities within the transformation ‘targeted’ funds and present our Operating Plan for 2016/17 which we believe is both realistic whilst aspirational, developed in line with the spirit of the STPs which will underpin delivery of the Five Year Forward View.


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Despite high aspirations committed to, the impact of continued activity growth year on year (circa 26% growth in red 1 calls and circa 22% growth in red 2 calls in the last two years) has resulted in significant unabated pressure upon already stretched resources and consequently we have been unable to match capacity with demand. This is reflected in our inability to deliver, despite our best endeavours, against national performance targets. It is projected that this challenge is set to continue over the next year. Our 2015/16 NHS contract contains agreed trajectories for Red performance within the Service Development Improvement Plan. As Red 2 performance did not meet the trajectories set by CCGs this triggered the Lead Commissioner to request a Remedial Action Plan (RAP). We have developed a RAP with forecast trajectories indicating when we would deliver against the national performance targets and how this may be achieved. Subsequent meetings have been held jointly with the lead CCG, NHSI, NHSE to discuss the capacity gap which exists which is preventing us being able to deliver sustainable performance.

1.1 Remedial Action Plan (RAP) - Actions to Improve Performance

We have taken a number of actions towards improving patient care and performance. These include a deployment review, clinical hub implementation, development of the Associate Ambulance Practitioner scheme and CAD upgrade. A two year RAP was commenced in 2014/15 with the priorities being identified for implementation for 2015/16 of:

Stabilising and Improving Performance:o Recruitment and training of 400 Student Paramedics;o Up-skilling 60 Emergency Care Assistants to Emergency Medical Technicians (EMT) and 40

EMTs to Paramedic;o Continued fleet replacement to maintain all frontline vehicles less than five years old;o Re-investment of corporate spend into frontline delivery through robust benchmarking; ando Securing and implementing a new CAD.

Engaging with Healthcare Partners

Creating a positive workplace culture with implementation of an Organisational DevelopmentProgramme.

Working closely with the commissioners in developing the RAP it has been recognised that in order to achieve and sustain performance there is a fundamental capacity gap which CCGs were not able to fund and which we could not afford without further financial support. An updated RAP for 2016/17 delivery has been developed setting out a trajectory for recovery of performance but requiring significant financial support. This has recently been submitted to the CCG for consideration. However, this has not yet been agreed with the Commissioners. We continue to engage with the CCG with a view to negotiating an agreed way forward. The future availability of Strategic Transformation Funding (STF) for ambulance trusts is unclear and we have not factored any such funding into our financial plans. To underpin recovery, we have embarked upon a period of significant change by developing a new Trust strategy complete with a new operating model that better supports patients and the health system as a whole. This is awaiting final approval by all stakeholders and, if approved, we will require support in securing additional capacity whilst we re-engineer our model to deliver a new integrated system for urgent and emergency care. The following are enablers to sustained recovery in service delivery:

• Maximising EEAST involvement in urgent and emergency care initiatives;• Greater collaboration with health and social care partners to help ED avoidance and treat patients

closer to home;• Increased collaboration with emergency services to increase our reach, especially around

exploring co-responder schemes; and• Volunteer events to better utilise and engage with community first responders.

We are continuing to develop work streams to deliver against these enablers recognising that they will not only underpin our own recovery in performance but also that they will contribute towards the STP.


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2. 2015/16 Integrated Performance Summary

2.1 Quality Indicators 2015/16 YTD

We have continued to perform well as a Trust from a quality perspective within 2015/16. The following is a summary of the Patient Safety and Quality information derived from the Trust’s internal monitoring processes, up to and including December 2015 (extracted from Quality Report February 2016).

Safety There have been no ‘Never Events’ in the 2015/16 financial year to date andSerious incidents are around 30% lower in 2015/16 Year to Date (YTD) thanthe previous year, despite significant increases in staff reporting which we have encouraged and welcomed;

Duty of candour Of 20 current open Serious Incidents reported, all had Duty of Candour discharged;

Infection control Vehicle/premises audit cleanliness compliance level of 94.1% (target 85%);

Complaints The Trust received 15% less complaints 2015/16 YTD compared to 2014/15 (split broadly as follows: 45% delays in ambulance attendance, 20% attitude of staff, 16% clinical assessment and treatment and 19% other);

Friends/family test 100% of patients who responded to the Emergency Service postal survey andhad used the service during February 2016 advised that they would either be ‘likely’ or ‘extremely likely’ to recommend the service to a friend or relative.

93.6% of Patient Transport Service Friends and Family Test respondentsin February 2016 answered that they would be either ‘likely’ or ‘extremely likely’ to recommend the ambulance service to friends and family if theyneeded similar care or treatment.

2.2 Operational Performance (*Extract from Integrated Board Report February 2016)

Performance remains challenged with:Regional performance below the national standard for Red 1, Red 2 and Red 19 YTD; Green 1 performance was above locally agreed standards but Green 2 was below YTD. Activity above contracted levels at 6.04% week ending 14/02/16*; Unit Hour Production is below core with added pressure from Student Ambulance Paramedic

abstractions for University*; Average abstractions at +35%*; Delays at Hospital causing significant issues in delivering a safe and timely service*; Sickness levels at 5.4%*; Additional Private Ambulance Service now secured for period of 15/02/16 – 20/03/16*; Cleric CAD now implemented in Norwich*; and Deployment trial complete with good outcome.Monthly performance figures are summarised in the chart below.Chart 1 Delivery against National Performance Targets – Monthly

We are committed to improving service delivery and have developed a Remedial Action Plan (RAP), requiring additional funding, which will enable us to better match demand with resource capacity and hence improve our service to patients and performance. This is covered in more detail in paragraphs 10.1 to 10.3.


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2.3 Ambulance Clinical Quality Indicator (ACQI) Performance Summary

Four of the eight ACQIs were above the set targets for January 2016, with three of the remaining four ACQIs improving from December 2015, with the exception of overall Return of Spontaneous Circulation (ROSC) at hospital.

Performance against national ACQI targets, summarised in the table below, indicate that there has been significant improvement up to (and including) month 8. However, with a continued deterioration in delivery against response time standards there has also been some deterioration in achievement ofclinical standards. We are continuing to carefully monitor delivery against ACQIs and anticipate an improvement with the implementation of the RAP in the short term and new operating model in the longer term, both contingent upon securing additional funding.

Table 1 Delivery against National Ambulance Clinical Quality Indicators - Monthly

2.4 2015/16 Financial Performance

Month 11 surplus position of £2.8m, a £3.2m favourable variance against a planned deficit of £(0.4)m;

Remaining financial pressures include:o Provisions for injury benefit;o Activity under contract;o Performance penalties on R1, R2 and R19, local penalties on Floor and Tail targets; ando Private Ambulance Service (PAS) usage.

Notes to financial position:

o Activity below contracted levels overall by 0.11% at Month 11 and is forecast to slightly exceed contracted levels by end of March. Activity remains inconsistent across the Region with some areas experiencing very high levels above contract and others being consistently below;

o Tight controls are being maintained over PAS but there is some lack of PAS availability, meaning spend levels are below those planned;

o Overtime continues at high levels;

o Penalties are fully provided for in the position as the negotiations with the CCGs for reinvestment are not yet concluded for the RAP; and

o EEAST is forecasting delivery of its CIP target although a high level will be non-recurrent in nature, increasing the CIP challenge for 2016/17.

We are forecasting delivery of a surplus of c£2m, comprising the work the Trust has managed to carry out towards some achievement of the NHSI requested stretch target of a £1.7m surplus together with the transfer of £1.5m capital to revenue. However this position does not include the withholding of penalties of £1.9m which the CCGs could potentially impose in respect of non-agreement of the RAP. Should this occur the Trust will show a surplus for 2015/16 of only £0.2m.

ACQI Target 2015/16

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Ja n-16

ROSC at hospita l (overall) 25.0% 24.4% 25.9% 29.3% 25.6% 27.0% 26.2% 30.0% 28.9% 23.0% 21.8%ROSC at hospita l (Utstein) 51.0% 38.9% 40.0% 56.3% 43.8% 56.3% 45.8% 63.3% 57.1% 43.5% 45.7%Survival to discharge (overall) 7.0% 6.8% 4.8% 6.8% 6.4% 4.2% 8.2% 9.4% 8.5% 4.9% 5.4%Survival to discharge (Utstein) 25.0% 23.5% 17.9% 29.6% 15.4% 21.4% 39.1% 47.1% 25.0% 9.1% 27.3%PPCI < 150 95.0% 96.1% 94.0% 85.7% 90.3% 92.8% 89.0% 95.6% 95.7% 94.6% 97.2%STEMI care bundle 80.0% 84.5% 76.1% 81.7% 83.0% 79.7% 79.1% 74.8% 85.5% 86.0% 93.4%Stroke HASU < 60 56.0% 62.4% 52.5% 52.7% 49.1% 51.0% 44.6% 51.5% 43.4% 45.1% 46.2%Stroke bundle care 95.0% 96.5% 98.0% 98.2% 97.4% 98.2% 98.2% 98.2% 97.8% 96.5% 97.9%


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3. Approach to Activity Planning

3.1 2016/17 Activity Plans

Whilst activity modelling undertaken so far indicates that, on average, activity has increased year on year by around 3% and that this is set to continue, it is evident from analysis that demand in red (potentially life threatening) calls is growing at a higher rate than other categories of call, placing the Trust under additional pressure due to the more complex response these calls require and the performance targets which it has to meet. This is demonstrated visually within the chart below which summarises call demand by category from April 2013 to date. A forecast of future demand has been made using past growth overlaid with seasonal variation.

Chart 2 Call Activity by Category of Call 2013 - 2016

3.2 Matching Demand with Capacity

We have continued to work closely with the commissioners in developing our RAP to deliver national performance standards and it has been recognised that in order to achieve and sustain performance there is a fundamental capacity gap which CCGs were not able to fund and we could not afford without further financial support. This capacity issue has led to a reduction in performance delivery which is demonstrated within the chart below.

Chart 3 Delivery against Performance Targets

Recognising that capacity does not meet demand, discussion is on-going with Commissioners in respect of the possibility of additional funding to improve performance which would allow for:

Short term improvement through additional agency and PAS; and Long term and sustained improvement through the development of a new operating model with

appropriate workforce skill mix.

3.3 Activity Return Planning Assumptions

Returns include activity assumptions underpinned by:

Overall growth of circa 3% (although CCGs continue to work on individual plans); and Higher growth (minimum circa 6%) within red 1 and 2 call categories.

We are planning to change the way in which we respond to patients as summarised in table 2 in chapter 6 with an increase in hear and treat and see and treat which will enable us to increase capacity within our existing resources and provide a better service to patients closer to home.

10, 00 0

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Activ

ity

Red … G r een … T o t a l d em a nd L i nea r ( To t a l d em a nd )

50.0%55.0%60.0%65.0%70.0%75.0%80.0%85.0%90.0%95.0%

2013

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Red 8 m inute performance Green performance

Linear (Red 8 minute perform ance) Linear (Green performance)


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4. Approach to Quality Planning

4.1 Quality Indicators

Central to the ambulance service are the nationally agreed Ambulance Quality Indicators. We areworking with our commissioners to ensure commissioning arrangements are in place related to delivery against these, focusing upon key outcome measures related to safe and effective care with a good experience for patients. We are also focusing upon our service response to patients through the delivery of the national performance standards and upon the methodology for harm analysis against tail breaches (forecast to reduce if RAP is implemented – see 5.6). We recognise improvement is required in our delivery against these indicators and are working with the CCG to develop improvement schemes such as the Integrated Clinical Hub. Additionally, discussions with Commissioners are focusing upon our ability to deliver high quality care in relation to:

Mental health triage and conveyance to safe locations when needed (avoiding Emergency Departments/Police cells);

Service delivery model changes related to appropriate and best response to patients; CQUIN priorities including clinical hub development; End of life care; Improved pathway for patients, working with 111; and Identification of alternative patient pathways and direct referrals.

A number of local quality requirements are also commissioned relating to safe and effective care with good patient experience, underpinned through effective and appropriate training and development of staff. We believe that it is important to ensure that all patients, when required or identified, have access to a registered healthcare professionals, whether physically or remotely, who are also able to provide advice to other clinical staff to support their patients’ care. Through our triage, assessment and treatment models we will be able to identify and assign a named clinician to patients, leading their episode of care. This is supported through our workforce planning and current service delivery model.

4.2 Quality Plan Priorities

We have identified a number of quality plan priorities for 2016/17 which are as follows:

Mandatory priorities:o Timely patient response;o Heart Attack care;o Cardiac Arrest care; ando Friends and Family score.

Trust selected priorities:o Sepsis care;o Dementia; ando End of life care.

Each of these priorities has an agreed measure of improvement, a plan for delivery and a mechanism for reporting progress against each through bi-monthly reporting to the Quality Governance Committee which oversees the Quality and Patient Safety Strategy.

The Quality and Patient Safety Strategy, developed and approved in 2015/16 with the purpose ofimproving patient safety and reducing avoidable harm, contains a range of actions supporting our Trust in ‘signing up to safety’, achieved through engagement with staff and stakeholders with learning from patient experience at the centre. This strategy continues and contains the following domains:

Honesty; Responsiveness; Support; Safety; and Listening.


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4.3 Risks to Delivery of Quality Plan

Risks relating to delivery of the quality plan are reported and managed through risk registers and the Board Assurance Framework (BAF). Risks registered relating to the Trust’s priorities are monitored through assurance groups and the risk register is reviewed by the Executive Leadership Board and the Trust Board. Each risk and item on the BAF has defined actions/mitigations that are monitored on a monthly basis.

The key risks relate to:

Failure to implement and deliver the quality and patient safety strategy;

Failure to deliver the Trusts workforce strategy;

Failure to consistently deliver key performance targets;

Failure to form strategic alliances with national and local partners; Failure to create and embed a culture of performance and accountability;

Lack of stable and effective Trust board; and

Failure to deliver a lean and financially viable organisation.

Each risk is managed through the Clinical Quality and Safety Group (CQSG).

4.4 CQC Assessment and Actions Taken – Historical

The CQC inspection in 2013 highlighted two areas for improvement which were to responding to patients more quickly in life threatening situations and having enough suitably qualified staff to meet national response times. This emphasized the importance of addressing issues relating to recruitment of staff and appropriate skill mix of registered and non-registered staff.

Following this we implemented an ambitious recruitment programme which continued into 2016/17seeking to ensure legacy vacancy levels were addressed, appropriate skill mix planned for, hard to recruit to areas supported and staff development provided.

During 2016/17 the Trust will continue with this and also:

Begin the implementation of a new operational and clinical model if supported by our stakeholders;

Recruit further student paramedics to support vacancy levels, anticipated turnover and support development;

Recruit non paramedic and multi-disciplinary clinical staff to ensure that the Trust’s long term financial model is one of sustainability and patient safety;

Provide a range of development opportunities to clinical staff for progression and development in line with the workforce and service delivery plan; and

Participate in implementing learning from Serious Incidents reported through a national database used by all ambulance trusts.

4.5 CQC Assessment and Actions Taken – Current

We have recently been engaged in a CQC inspection and have received some informal feedback that reflects our continued efforts to ensure patient care and safety are a priority. The initial feedback is provided to recognise early both areas of best practice and those requiring action and we will be celebrating and initiating immediate work streams to capitalise upon this whilst we await the final report.

In the coming months, our Quality Development Team will transition to be our ongoing Quality Improvement and Professional Standards Team and will lead implementation of any action plan that may emerge in due course from the final report from the CQC inspection.


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5 Approach to Quality Improvement

5.1 Risks to Quality

The top three risks to quality which have been identified through the BAF are workforce, quality and patient safety and compliance with regulatory frameworks. Each risk area for quality contains a number of objectives and actions for managing the risk and is overseen by CQSG.

5.2 Risk Governance Framework

The Trust has a framework of groups that look to provide forums for assurance, risk management and decision making. These all relate to quality and range from opportunities for staff innovation through to Board sub-committees. Sandy Brown, Director of Nursing and Clinical Quality is the named executive lead. The central decision making forum within the Trust is the Executive Leadership Board(ELB). This is supported through the CQSG which oversees quality, clinical practice and safety. This group has a range of sub-groups which support with leading and delivering important work plans and compliance and cover:

Clinical development and effectiveness; Learning group covering incidents, complaints, serious incidents, litigation findings, trends and

themes; and Compliance – Health and Safety, Safeguarding, Infection Prevention and Control, Medicine

Management

For assurance purposes CQSG reports to the Quality Governance Committee of the Board which is chaired by a clinical non-executive director where quality is discussed and assurance sought. This is achieved through the triangulation of evidence, reports and discussions. These groups have terms of reference and minutes taken along with reports to CQSG and sub-Board committees as required.

5.3 Quality Improvement Methodology

The Trust uses a range of systems and processes in order to identify, address and monitor incidents, instigate development and identify quality issues in order to highlight and deliver improvements. These can be at a local or Trust wide level and also national ambulance level based on a range of information gathering and feedback. The overarching principles for improvement methodology is based upon:

Building openness and transparency with patients, staff and stakeholders; Learning into action through incidents, complaints and feedback; Listening and actions; Accountability throughout the organisation including where care is delivered to patients; Respect to patients, staff and stakeholders; and Communication that is effective.

The main focus is around ensuring as many routes are open to feedback from staff, patients and stakeholders. This is achieved through:

Safety walk about audits by managers and Trust User Group members; Monitoring and learning from complaints, incidents, concerns and serious incidents; The introduction of a quality development team who can assist with the triangulation of feedback

from station visits and staff engagement; PEER reviews conducted internally and by commissioners and; Auditing on clinical outcomes through an audit plan that includes aspects of patient safety. This

includes specific audits for Infection Prevention and Control (IPC), medicine management and safeguarding;

Patient Experience surveys to a range of service users Use of the PROCLUS Lessons Identified Debriefing system by all ambulance trusts to share

lessons learnt and actions required from a range of events e.g. Serious Incidents, Coroners Inquests and Untoward Incident Reports.


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5.4 Overarching Quality Priorities

Our overarching priorities are delivered through work streams that focus on safety, effectiveness and patient experience, cover a range of measures aimed at ensuring patients with life threatening issues are responded to and cared for in a timely manner. The following are three priority areas, with associated objectives, to support this:

Delivery of the patient safety strategy objectives for year 2; Continuation of the Quality Account Priorities from 2015/16 into 2016/17 subject to consultation

and formal agreement (paragraph 4.2); and Improved response to patients through appropriate delivery of commissioner agreed RAP.

5.5 Well Led Framework

The Board have undertaken a self-assessment under the Well Led Framework by the NHSI. This is in line with consistent Board development days, which the NHSI have also been a part of. AQUA will also be joining the Board to measure them against the self-assessment from an external perspective.Current proposed actions for 2016/17 include:

Identification and management of sepsis. Robust clinical assessment and patient pathway usage. Establishment of individual performance monitoring capabilities. Continuation of quality in cardiac care. Management of patients with asthma. Review of the implications of the Care Act. Embedding the actions and learning from the Lampard report.

Reviewing against the assurance requirement that the Association of Medial Royal Colleges’ (AMRC) guidance on responsible consultants has been fully taken into account as part of the discussions and discussions on our service delivery model and building of our integrated clinical hub; this looks to support the ambulance service interpretation of the AMRC guidance in situations where episodes of care are time limited. By ensuring that this is linked with our triage, assessment and treatment models we will identify a named clinician for patients who will lead their episode of care. This is supported through our workforce planning and service delivery model. Our aim is to ensure that all patients, when required or identified have access to a registered healthcare professional which can occur physically or remotely including advice to other clinical staff to support the patient’s care.

5.6 Approach to Quality Improvement Alignment with RAP and Resultant Reduction in Tail Breaches

Improving quality and safety is an integral component of our RAP and has been a key focus for our Trust given our response time performance. Implementation of a new operating model underpins sustainable performance improvement and will be supported by an increase in the use of agency and Private Ambulance Service (PAS) resource. Deep dive analysis has demonstrated a clear correlation between the use of PAS/agency (i.e. additional capacity) and performance improvement. We anticipate that, with an improvement in performance underpinned by an increase in PAS resource, a reduction in tails and an improvement in quality of patient care provided will crystallise. However in the medium and longer term the Trust plans to shift to a more sustainable operating model that significantly reduces our reliance on PAS.

5.7 Seven Day Services

We already provide a 7 day service 365 days a year in relation to 999 response; we recognise that 7 day service provision undertaken by other providers may lead to an increase in out of hours and patient transport services the latter of which is not yet consistently commissioned 7 days per week. This may result in increased activity which we will need to address jointly with CCGs but may also result in a shift of demand patterns across the week. We will continue to work closely with our commissioners to better understand the likely impact and how the ambulance service (both our emergency and non-emergency patient transport services) can support this across the system. In addition through the delivery of our new operating model we will provide a consistent and integrated ‘front end’ for urgent and emergency care 24/7 that will be able to effectively refer to services developed through the 7 day working implementation.


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5.8 Quality Impact Assessment (QIA) Process

Cost improvement plans (CIP) and improvement programmes are identified using a number of techniques including:

Clinically led initiatives and ideas adopting best practice; Analytical and benchmark driven opportunities; Bottom up initiatives identified by staff; Top down Trust wide schemes; and Externally driven initiatives from horizon scanning.

CIP targets, established during budget setting, are provided to managers who are then responsible for developing worked up delivery plans for CIP initiatives that are at least equal to the CIP target. Once developed, a multi-disciplinary team workshop comprising senior management is held to review and challenge each CIP scheme to ensure that there is no adverse impact upon quality of care, performance, staff morale etc. This workshop is attended by the Medical Director and Director of Nursing and Clinical Quality to ensure an impact assessment upon quality (QIA) is robust.

Once formal sign off of each scheme QIA has been obtained a transition into a CIP tracker occurs allowing monitoring and management of CIP progress by finance managers.

CIP trackers are monitored monthly for delivery against financial target and non-financial KPIs established as part of the QIA process and reported monthly through the Finance and Performance Committee. Any deviation from plan is escalated through the Senior Finance Team forecast reports and a Senior Trust meeting (including Executive attendance) is convened to discuss deviation from plan and remedial action to be taken agreed to bring CIP scheme performance back on track.

We also provide an additional layer of assurance through our commissioners and report on our CIP development and progress through the Contract Finance Sub-Group. The Trust Board is assured that CIP schemes are not impacting negatively upon quality via receipt of CIP reporting from the Finance and Performance Committee.

5.9 Triangulation of Indicators

Acknowledging the importance of monitoring the impact of our strategy upon quality, operational and financial performance we have developed a monthly integrated performance dashboard which is presented to the Board. This report summarises key performance indicators side by side and allows the Executive team to review and analyse performance and the impact of decision making. Key performance indicators reported include:

Performance indicators - red & green call performance v contracted and actual activity v ACQIs; Workforce indicators - A&E monthly turnover %, vacancies by function and sickness levels; and Financial indicators – operating surplus.

Also included within the report are the following key performance indicators:

Serious incident numbers; Vehicle cleanliness; Complaints; Red and green performance (detailed) trends; Hospital handover delays and turnaround; and Roster coverage and abstractions.

By ensuring that all of these KPIs are reported and considered in a single simple and visual report the Trust Board are provided with an overarching view of performance and items impacting upon it.

Figure 1 Example Integrated Performance Dashboard


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5. Approach to Workforce Planning

6.1 Approach to Workforce Planning

We are planning to ensure we have the appropriate capacity and level of skills required to deliver high quality patient care aligned with our Urgent & Emergency Care Review-based strategy. This will depend upon the method of delivery of care and we recognise that changes in the way care is delivered will impact upon workforce requirements. We are planning to increase hear and treatsignificantly and see and treat, and reduce inappropriate conveyance as summarised below.

Table 2 Movement in response type

As a result of a movement in response type our workforce of the future will be more highly skilled, operating across traditional boundaries, accessing improved decision-support, more clinically focused on diverging patient needs, but with sufficient capability and capacity to manage the movement and flow of patients through the wider system effectively. It is also anticipated that traditional working practices will need to be reviewed and staff are likely to be operating in a more integrated way with health and social care, other public services, the voluntary sector and specialists.

Currently, work being undertaken to clarify the future workforce model is based on a number of assumptions, many of which are dependent on additional funding if they are to be achieved at the speed required to make a significant change to service delivery for patients. If additional funding is not made available, the pace of change will be considerably slower. It is important to note that our new model is likely to deliver considerable savings to the health system as a whole.

A key assumption of this model is the transition to a graduate paramedic workforce, which therefore requires a review of the level and skills of the support role currently fulfilled by technicians. This is currently being driven by the Paramedic Evidence Based Education Project (PEEP) at a national levelby Health Education England (HEE). This recognises that the care delivery by paramedics needs to be supported through an educational framework adequately preparing and supporting them. A career framework allows specialisation of roles and practice with a broad range of careers to follow. It is alsoimportant we are sighted on the outcome of the independent prescribing consultation for paramedics.

All of this can combine to ensure that paramedics operate at their full scope of practice and offer enhanced capabilities for treatment in the community/at home environment. It is assumed that the rate of onward conveyance to hospital following attendance by the Ambulance Service will reduce and, where appropriate, there is likely to be an increase in the number of incidents where there is no immediate threat to life, requiring a paramedic to carry out a face to face clinical assessment. This will likely see more patients being treated safely at home.

In addition we will be introducing enhanced diagnostic and triage tools to support decision making on scene, as well as working closely with other providers to develop alternative referral pathways, including direct referrals to specialist wards or centres, thus avoiding the emergency department. We will also look at how this can integrate with our Patient Transport Service to ensure appropriate transport is utilised.

To support the workforce plan and retention strategies, a review of the emergency care staff development pathway has been undertaken. This was based upon the career framework, PEEP report and anticipated service needs and providing clear progression through the attainment of knowledge, experience and skills and is potentially available for all staff. The development of pathways should be agreed and implemented with the support of Health Education England and our Commissioners. This ensures that there is a strategic alignment along with financial sustainability.

Response type Now % Future %Hear and treat 5% 20%See and treat 35% 40%See and convey 61% 40%Total 100% 100%


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6.2 Governance Process - Board Approval of Workforce Plans

The workforce plan is produced in conjunction with the strategic and financial plan and agreed by the Trust Board and Commissioners on an annual basis. Commissioners, Health Education England (HEE), NHSI and NHS England monitor this plan against target on a regular basis.

The Board receives monthly reports and the Performance and Finance Committee receive more detailed progress reports to review and agree. Commissioners and Health Systems have arrangements in place to monitor our vision with the strategy for the system as a whole, ensuring there is alignment and complimentary provision of service for our community.

The work currently being undertaken to clarify the future workforce model is based on a number of assumptions, many of which are dependent on additional funding, currently being discussed with Commissioners, if they are to be achieved at the speed required to make a significant change to service delivery. If additional funding is not made available, the pace of change will be considerably slower.

Degree programme for paramedics commenced in September 2014 with graduation 2017; Commence Vocational Qualifications in 2016 for non-registered ambulance staff reviewing the

scope of practice to better fit the needs of patients; Operational staffing model will be patient needs and demand led; Specialist Paramedics rotating between operational deployment, Clinical Hub, Minor Injuries, GP,

Out of Hours Service, etc; Significantly increase in training numbers of Specialist Paramedics from 2016 onwards; Advanced Paramedics clinically supervising/supporting Specialist Paramedics, Specialist

Paramedics providing supervision and professional advice to paramedics, Paramedics supervising other clinicians;

Clinical Governance of workforce will be assured via appraisal processes which will be developed in line with other professions;

Masters programmes for Advanced Paramedics commencing summer 2016; and Increased CPD time – modelling for three days per calendar year with an intention to create new

roster models that build in professional development time Building an integrated clinical hub with a range of healthcare professionals, support staff and

processes.

There is also scope to enhance the skills of the current cohort of ambulance care assistants to undertake lower acuity urgent and unscheduled work, notably discharge and transfers to facilitate better support flows across the wider system along with building system resilience of specialised treatment capacity and to achieve this the following actions are planned:

Train Emergency Care Assistants to Technicians and Associate Ambulance Practitioners; Introduce an accelerated apprenticeship programme to attract new people into the organisation;

and Education and development of new paramedics will be passed through to our University partners,

with the Trust becoming a provider of quality placement experience.

This journey has commenced with our first BSc cohorts expecting to graduate in 2017. Our EMT to paramedic development will be through our University partners along with our student paramedic recruitment. As our BSc partnerships strengthen and our workforce stabilises we will look to complete this move in the next two years.

We have an absolute commitment to supporting our student paramedics, who were integral to our turnaround, on their education pathway to become paramedics. The new Clinical Pathway above is recommended as the future workforce strategy providing benefits for patients and avoidance of admissions to hospitals, aligned with the spirit of the STP.


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6.3 E-rostering and Reduction in Reliance on Agency Staffing

We have a rostering system called GRS that connects with OHIO (Occupational Health System) providing live management information on attendance and sickness status. We have not used agency paramedics prior to last month. This is a new initiative aimed specifically at peak demand and this provision will be monitored to ensure the usage is proportionate. Key events/holidays have their own planning focus.

• Managers will have live manpower information, improving planning and utilisation of staff e.g. short notice sickness and will lead to less downtime within the system.

• Targeted reports assist demand management resulting in a coordinated approach across the system to facilitate people, vehicles and equipment.

• Rotas changed to reflect peak periods of demand.

• Unit Hour of Production (UHP) is a key priority and regular daily conference calls ensure any issues are dealt with on a daily basis.

6.4 Approach to Workforce Planning Alignment with Local Education and Training Board Plans

We work closely with Health Education England (HEE) to ensure the future needs of the workforce are identified and met. The Head of Education provides regularly progress reports to HEE and there are also regular meetings to monitor progress.

6.5 Triangulation of Quality and Safety Metrics with Workforce Indicators

Datix is used to report and monitor all risks, including those relating to the workforce and a report regularly produced and presented to a Board Sub Committee of Quality and Governance which allows effective oversight from a senior team, facilitating management and control. In turn the Trust Board receives regular reports on quality and risks and has recently designed integrated performance reports which combine performance, quality and workforce reporting.

We use both the Board Assurance Framework and the Risk Register to monitor risks across the organisation. The Risk Register is a way for every service line to annotate its risks and determine a score against each one. If there is a risk that is either escalating or requires support to mitigate, this can be escalated via an increased scoring matrix or by highlighting to a Head of Department for consideration as a Principle Risk or for addition to the BAF aligned to one of the Strategic Risks. The Audit Committee reviews Risk Registers at their meetings and the newly formed Management Assurance Group (MAG) (formerly the Risk Management Group) feeds directly into this committee, highlighting risks which may require further scrutiny with possible escalation to the BAF for Board visibility. The quality team review risks via every group meeting agenda with the Clinical Quality & Safety Group being the overall assurance group that will escalate any substantial risks up through the MAG or the BAF. Each Director meets monthly with the Safety & Risk Lead to discuss their risks. The risk assessment process forms a much more robust means by which to make the risks visible for trials or projects and are now required for each proposal.

Since it is difficult to find any singular and direct correlation with any one workforce KPI to performance and quality we have designed an integrated dashboard to include a variety of workforce KPIs allowing comparison of movements within each to each other. This report is very visual, making it easier to understand fluctuations in performance. These KPIs include:

Monthly staff turnover % Trust sickness levels; Vacancies by function current month; Roster coverage; and Planned overtime and abstraction %.

Reported alongside these are performance and quality metrics allowing risks to be identified and monitored visually at Trust Board level.


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6.6 Application and Monitoring of Quality Impact Assessments for all Workforce CIPs

Mandatory learning - core knowledge book and separate answer book, moving to e-learning for appropriate topics.

Robust mentoring mechanisms to ensure compliance. Applies to all staff including students. All training trajectories set with each locality avoiding peak demand/abstraction. Monitored and reported through ELB, OLB and Board.

6.7 Plans for any new Workforce Initiatives Agreed

Plans outlined above have been converted into a detailed breakdown on the workforce required in the future (described below). This plan is being discussed with stakeholders through our commissioning process but also via health systems meetings. Funding for these plans has yet to be agreed.

6.8 Systems in Place to Regularly Review and Address Workforce Risk Areas.

Workforce risk are identified on Datix, the risk management system, and discussed at the Quality Governance Committee (a subcommittee of the Trust Board). Regular workforce reports are presented to the Trust Board with any associated risks.

6.9 Balancing Agency Rules with the Achievement of Appropriate Staffing Levels and Alignment with RAP

We have historically used a low level of agency resource and have worked to reduce use of PASusage over the past few years. However, as demand has continued to grow at a pace which has outstripped our ability to match with resources, we have suffered from a deterioration in our ability to deliver against national performance targets. Consequently we have developed a RAP which seeks to improve performance using additional agency resource and PAS in the short term and are in negotiation with the CCG and NHSI to secure additional funding to implement this change. However, an agency cap has recently been imposed upon us, based upon our historically low agency usage, which will inhibit our ability to secure agency and PAS resource to the required levels. We are in communication with the NHSI to try and increase the agency cap which will increase our ability, assuming we are successful in securing RAP funding, to invest in additional agency and PAS resource to the required level.

7. Approach to Financial Planning

We recognise our contribution to the wider health economy financial performance and are planning to deliver a surplus of £1.5m (imposed by NHSI) in 2016/17, underpinned by effective cost controls and delivery of a challenging CIP target of £6.7m (circa 3% of revenue).

As has been discussed previously, we are committed to improving our performance against national quality indicators through the development and implementation of a RAP. Our RAP which has been developed and submitted to the Commissioners for consideration specifies a significant increase in resources required (particularly agency and PAS costs whilst we transition into a new operating model) to deliver improvements in performance.

It also contains plans for development of the Trust resource infrastructure (estate, IT, vehicles)through a new operating model. However, recently we have been presented with two problems that inhibit our ability to implement and deliver our RAP:

The NHSI have imposed an agency cap of £3m which will inhibit our use of agency and PAS which is central to our ability to improve performance; and

Our RAP has not yet been agreed with the Commissioners and so the ability of our Trust to improve performance is contingent upon agreement with the CCG.

Given the contingent nature of our ability to implement the improvements contained within our RAP(PAS increase and re-engineering of a new operation model) we have not included the cost of these within our 2016/17 plan.


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7.1 Financial Forecasts and Modelling

A summary of 2016/17 plan is provided in the table below along with underpinning assumptions.Table 3 Planned 2016/17 Financial Performance

Underpinning assumptions:

Clinical activity assumed to increase by circa 3% in line with historic trend and Commissioning;

2% net efficiency factor;

Capital Investment provided for of £8.5m including estates spend in supporting estate redesign;

Workforce costs have been increased by Agenda for Change and incremental drift inflation;

High non-recurrent delivery of CIP target for 2015/16 gives additional cost pressure in 2016/17;

CIP target of £6.7m;

A contingency of £1.2m, 0.5% of turnover, has been included;

No general winter funding reserve has been included (central NHS England guidance);

It is currently assumed in the budget that CCGs will wish to continue with the HALO scheme. Both income and cost is included, although currently only 7 of 17 schemes have been agreed.

Whilst provision for a net 2% efficiency factor and increased CNST premiums contained within ‘Delivering the forward View: NHS planning guidance 2016/17 – 2020/21’ have been included within our 2016/17 financial plan, adjustment for the following items will only be included once more certainty is obtained in relation to likelihood and value:

Commissioners are required to spend 1% of their allocations non-recurrently. This must be uncommitted at the start of the year; and

There is a requirement for commissioners and councils to agree a joint plan to deliver the requirements of the better care fund in 2016-2017.

7.2 Cost Pressures

The 2016/17 financial plan includes the following cost pressures:

Table 4 Cost Pressures Included within 2016/17 Financial Plan

2016/17 F i n a n c i a l Pla n Summary - I&E and KP Is 2016/17£ m

Revenue 234.9P a y (169.5)Non-pay (57.1)EBITDA 8.3EBITDA % 4.0%Non-operating expenses (6.8)Surplus 1.5Surp lus % 0.6%CIPs 6.7CIP % (real) 3 %Net eff iciency factor 2 %

Cost Pressures Inc luded within 2016/17 Pla n 2016/17£ m

Changes to Nat iona l Insurance contr ibutions 3.2Incremental drift (high due to the banding agreement reached i n 2 0 1 4 / 1 5 ) 2.7P a y budget increase 1.8HALO 2.6New Board a n d Executive structure 0.5Emergency Operations u n s o c i a l hours pressure 2.3Medicines management project 0.8Additio n a l staff posts (safeguarding, Bus iness Development Unit, CQC team, Emergency Operat ions) 0.4EPCR and CAD 0.5Non-recurrent C IP del ivery 2015/16 5.9Total 20.7


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7.3 Financial Forecasts and Modelling continued

The main impactors upon planned financial performance are summarised in the bridge chart below.Chart 4 Bridge Outturn 2015/16 Surplus to Forecast 2016/17 Plan

Key observations:

2% net efficiency factor

Includes impact of withholding penalties of £1.9m within 2015/16 surplus of £0.2m;

CIP target included of £6.7m is approximately 3% of revenue.

7.4 Risks and Uncertainties

Whilst a considerable level of detail has been confirmed which gives a good degree of confidence in2016/17 financial plan, there are still a number of risks and uncertainties which need to be noted as summarised in the table below. These risks will be reported and managed through Performance and Finance Committee.

Table 5 Risks and Uncertainties

-8

-6

-4

-2

0

2

4O

uttu

rn 2

015/

16 su

rplu

s

Recu

rren

t adj

ustm

ents

Cost

infla

tion

Inco

me

tarif

f inf

lato

r

Cost

impr

ovem

ent p

lans

Plan

201

6/17

0.2 0.6

(8.0) 2.0

6.7 1.5

No. Risk or Uncertainty Detail

1 Ability of the Organisation to deliver performance within the budget proposed

The Business case for the new operating model together with the latest RAP presented to Commissioners both identify the requirement for additional investment in order for EEAST to meet its performance targets.

2 2016-2017 Performance PenaltiesThe budgets allow no reserve for performance penalties, but current guidance indicates It would appear that penalties are probably not permitted to be enforced in 2016-2017 so this risk is reduced.

3 Commissioning uncertainties

The Commissioners are all under pressure to meet the rising costs of the Health sector. There is considerable uncertainty surrounding the ability of Commissioners to fund additional activity payments and so far there is no sign of positivity surrounding the potential for any additional investment.

4 CQUIN

The Clinical Hub business case requires the full amount of CQUIN. Our CQUIN schemes have been with the Commissioners in principle although further detail is to be developed jointly. Full CQUIN income has been matched with full CQUIN cost in the proposed budget.

5 CIPsWhilst the New Year target is lower than that of 2015-2016, the high proportion of non-recurrent schemes required to meet the 2015-2016 target show that recurrent schemes are increasingly difficult to identify.

6 Pay award This has been included at 1% but the final announcement on the actual detail of any pay award has not yet been announced.

7 Budget reductions

Some areas have incurred reduced budgets from those of 2015-2016. This has been necessary in order to meet the £1.5m surplus target imposed from the TDA and to enable the Trust to operate with a ‘realistic’ CIP target. These reductions have been based on the last 2 years performance together with plans for 2016-2017. The risk exists that budgets set may come under pressure from circumstances that arise during the coming year.


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7.5 Efficiency Savings for 2016/17

Historically the Trust has successfully delivered against CIP targets. The target CIP for 2016/17 has been established at £6.7m and underpins delivery of a challenging £1.5m surplus control total. A summary of CIPs identified v target for 2016/17 is provided in the table below.Table 6 CIP Target 2016/17

CIP schemes continue to be identified and developed and currently £4.1m has been identified from a target of £6.7m. The final split of CIP will differ from the above once sufficient CIP opportunities have been identified to deliver targets. We have applied our observations and lessons learned from 2015/16 to the current year CIP process which is mainly that of ensuring that we do not slip against CIP phased delivery and that CIP schemes delivered are recurrent in nature.

7.6 Identification and Development of CIP Initiatives

It is increasingly difficult to find more CIPs to deliver year on year, reflected in the non-recurrent delivery of 2015/16 of circa £5.9m. Whilst a number of schemes for 2016/17 have been identified they require further development and we have identified benchmarking, Lord Carter initiatives, transport and lease car schemes, rostering and scheduling, administration review and supplies restructure as areas of additional CIP opportunity. Mindful of the continued CIP challenge we continue to identify, develop and deliver CIP schemes without a fundamental redesign of our service. We acknowledge that future CIP delivery will be linked to our ability to obtain funding to deliver a new operational model.

7.7 Lord Carter’s Provider Productivity Work Programme

Aligned with the spirit of the Lord Carter report, we recognise that we have a duty to deliver any efficiency opportunities identified not only for itself but for the benefit of the wider health economy and NHS and consequently the areas of opportunity highlighted by this report below have been considered in relation to our own cost improvement plans: Improving workflow and containing workforce costs; Improving (hospital) pharmacy and medicines optimisation; and Improving estates and procurement management.

7.8 Agency Rules

Historically, spend upon agency staff and our use of agency and PAS has been of relatively low value. Performance recovery against national quality indicators is underpinned by our ability to increase our capacity to meet increases in demand is supported through the use of additional agency and PAS in the short term.

Aligned with agency rules guidance the NHSI has recently imposed an agency cap upon us of £3m which inhibits our ability to deliver against our RAP and, whilst we have communicated this issue to the NHSI and CCG, this issue remains unresolved. We are continuing to work with the NHSI and CCG to resolve this issue. Due to the contingent nature of the RAP, on the grounds that work streams contained within will require significant additional funding which has not been agreed, we have not included the financial impact of the RAP within our 2016/17 financial plans.

CIP Category - Identified v Target 2016/17£m

Pa y efficiencies (sickness ma na gement, trai ning etc.) 1.9Productivity efficiencies 1.0Procurement efficiencies 0.6IT and technol ogy a nd telecomms efficiencies 0.3Other i dentified 0.3CIP identi fied - by theme 4.1Uni dentified 2.6CIP ta rget 6.7


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7.9 Procurement

We have, for some time, been developing our approach to procurement with a view to maximising the value which we are able to deliver through obtaining most competitive prices for consumables, agency staff, vehicle costs, estate costs etc.

We are mindful of the Lord Carter of Coles work which has identified improvement in hospital pharmacy and medicines optimisation and estates and procurement management and believe that we are well placed to deliver savings against these key areas.

The following is an example of how we have been able to improve our purchasing power:

Member of NHS supply chain and national procurement hub;

Member of ambulance service collaborative organisation which enables collective purchasing power;

Signed up to a generic national ambulance uniform allowing better price to be obtained by all ambulance trusts through collective buying;

Purchasing items in bulk to benefit from volume discounts; and

Fixed term contracts to avoid inflation.

7.10 Transformation Funding

We are awaiting national clarification as to whether the Strategic Transformation Funding (STF) is available to ambulance trusts and have engaged with CCGs and the NHSI to obtain clarification in relation to this matter. We understand that the availability of STF will be dependent upon the following factors:

1. Deficit reduction;2. Access standards; and3. Progress on transformation.

We are confident that if STF does become available to ambulance trusts that we would meet the criteria within 1 and 2 but acknowledge that delivering against item 3 above is contingent upon securing additional funding and the successful implementation of the RAP.

This work is on-going and is a key area of critical discussions on our new operating model with CCGs. Due to the contingent nature of this we have not included this within our 2016/17 financial plan.

7.11 Cost of RAP and New Operating Model

Our proposed new operating model will transform the way in which we are able to deliver our services and will be implemented from 2016 to 2019 assuming we obtain additional funding (paragraphs 8.1 to 8.3) and is expected to result in a significant net cost saving to the wider health system.

Funding for this has not yet been agreed and consequently these costs have not been included within the 2016/17 plan.


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7.12 Capital Planning

The table below summarises planned capital spend for 2016/17 and assumes that the temporary reduction in capital resource limit from £10m to £8.5m in 2015/16 continues throughout 2016/17. The focus of the capital spend for 2016/17 is largely upon estates with a £5.2m allocation split into:

Projects continuing from 2015/16 £3.4m; and New projects for 2016/17 £1.8m.

Table 7 Planned capital investment 2016/17

Forecast capital spend is based upon delivery of the highest priority schemes adding most value to the Trust and ensuring that delivery of clinical strategy is underpinned by appropriate infrastructure which will contribute towards our proposed new operating model if funding is approved. Funding for the programme is generated from depreciation charges and cash produced from Income and Expenditure surpluses generated in previous years.

In particular 2016/17 planned capital investment will include aligning the current estate with the rationale of a more efficient hub and spoke type model which aims to deliver an efficiency in estate footprint and improved operational performance. This investment, will enable us to implement our new operating model and will improve the quality of vehicle and equipment preparation with associated governance,enabling us to readily shape-change or re-scale as we respond to the pressures of ever increasing demand. This will be achieved as a result of a whole system approach to vehicle preparation using a dedicated team of non-clinical staff who are trained and managed to deliver a high quality process that cleans, re-stocks and checks all vehicle, equipment and medical devices to ensure that they are fit for purpose and ready for use.

2016/17 capital spend will allow us to maximise the value added of any future investment into additional resources (contained within the RAP) and will also will underpin future planned re-engineering of the operational model should additional investment be secured following the current negotiations which are in progress with the CCGs.

There is one other large capital programme for the replacement of most of the original HART Vehicles. No capital allocation has been made for medical devices in 2016/2017, due to the successful early completion of the three year defibrillator replacement programme in March 2016. The latest RAP has been submitted to Commissioners for consideration, and we are still in negotiation to secure agreement for additional funding to allow transition towards sustainable performance improvement and a new operating model. Consequently, as any capital investment in relation to the new proposed operating model and RAP is contingent upon additional funding, we have not included these capital costs within our 2016/17 plan.

Planned Capital Investment 2016/17 £m Contribution to Clinical Strategy

IT Equipment 1.4 Infrastructure, network upgrades, medicines management system, Electronic Patient Care Records (EPCR) data repatriation

Estates projects 5.2 Progression of estates strategy to convert larger stations into depotsHART 2.0 Maintenance and replacement of estate/vehicles so fit for purposeTotal 8.5

Figure 2 Extract of Geographical Coverage of Operational Model


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8. New Operating Model

8.1 Our New Operating Model

Underpinning sustainable long term delivery of improved performance against national quality indicators and improving quality of patient care, as detailed within our RAP, we are seeking to move forward with simultaneous delivery of a number of initiatives which include changing the skill mix of its core delivery and providing new response models that are bespoke to the locality in which they work. We have developed a business case which specifies an operational strategy to create a clinical safety net for patients and staff with the further development and expansion of the Integrated Clinical Hub. As a multi-disciplinary virtual call centre this will be integrated within the local health system (contributing towards the emerging STP) working as an assessment and triage centre for patients, anadvice centre for staff and as a disposition for other local service providers. This, if approved and funding secured, will be our new operating model and will deliver sustainable long term performance improvement.

We have assessed patients’ needs across localities and are proposing different dispatch solutions for different areas, allowing for more patients to be treated at or near their homes. This will reduceunnecessary attendance and admission to hospital, resulting in the most appropriate resources being dispatched aligned with patients’ needs thereby reducing waiting, improving response times and increasing efficiency through better utilisation. This will also benefit our staff by creating an extended career ladder. Acknowledging that that delivery of the above will require partnership working, many of the changes outlined in the operating model business case create system savings through signposting patients to local health care solutions and away from the secondary care sector with the following significant system benefits:

Fewer conveyances resulting in reduced queuing at hospital (handover delays); and Fewer emergency referrals and streamlining of the emergency and urgent pathway.

To deliver these improvements we will require considerable additional recurrent annual investment which we estimate will deliver:

Higher and sustained performance; and Significant net cost savings across the health system.

Modernising and transforming the operational delivery of the ambulance service will drive positive change across the whole emergency and urgent health system, contributing towards the emerging STP. We are the only regional provider of health care and are working closely with all of the 17 Acute Providers and 19 CCGs and are continuing to engage with our fellow providers with a view to driving system change.

8.2 Transition to New Operating Model - Funding

The successful delivery of improved performance in the immediate future against national performance targets is only possible if we are able to secure additional funding for the use of PAS and agency staff in the short term to increase our capacity in line with ever increasing demand.

This will enable us to transition to a new operating model, also contingent upon securing additional funding, which will bring significant net system efficiencies.

Once we have agreed funding for additional resource we will instigate a concerted campaign to secure additional capacity as swiftly as possible. However, until agreement of funding is received we are unable to move towards this. Currently we have an agency cap of £3m which is significantly short of the required level of funding necessary to deliver the RAP.

We are in continued negotiation with the NHSI and CCGs to resolve this.


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8.3 Structure of a Flexible and Integrated Model

The impact of re-engineering our current service model to the new operating model, combined with initiatives currently under way, is represented in the diagram below which shows how effective care may be delivered by working towards a more flexible and integrated operating model. This complements working towards an effective STP.

Figure 3 Elements of a Flexible and Integrated Model

The new operating model will consist of a central integrated clinical hub with local ‘spoke’ services (figure 4) that are tailored to the needs of the population they serve with priority elements covered in our CQUIN case for 2016/17 (with the remainder highlighted within the new operating model business case).

However, again it is important to stress that this new model will deliver significant savings to the health system as a whole through safely using conveyance only when it is the most appropriate option and when all other opportunities have been exhausted.

In addition to the above EEAST plans to develop, in collaboration with local STPs and CCGs, a suite of local options or ‘spokes’ that integrate with the main clinical hub and offer enhanced benefits to the community model.

While this may include frailty cars, mental health rapid response, care home services and integrated community health models, it does not seek to replace existing effective services, but rather to collaborate with them.

This will be supported by our transformed workforce model which places the emphasis on significant growth in our Advanced Practitioner level.

Figure 4 Integrated Clinical Hub


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9. The Five Year Forward View (FYFV) – Emerging Sustainability and Transformation Plan (STP)

9.1 FYFV Rationale

The FYFV sets out that whilst the NHS has dramatically improved over the past fifteen years there is now broad consensus on what a better future should be. An acknowledgement is made that a radical upgrade in prevention and public health is necessary with patients gaining far greater control of their own care and that this can only be possible if the NHS takes decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, and between health and social care. The FYFV proposes that, across the NHS, urgent and emergency care services will need to be redesigned to integrate between A&E departments, GP out-of-hours services, urgent care centres, NHS 111, and ambulance services and consequently the achievement of this will need to be system wide. Therefore, the link into any emerging STP is clear.We are mindful that any initiatives we undertake should contribute to any emerging STP and FYFV, and whilst the STP is currently still subject to change we believe that the initiatives we are currently engaged in delivering facilitate contribution towards delivery of the FYFV ‘must dos’ as demonstrated in the table below.

Table 8 Current Trust Initiatives – Alignment with FYFV National ‘must dos’

9.2 Emerging Sustainability and Transformation Plan (STP)

We are fully engaged and committed to delivery of the intended triple aims of the STP which are:

1. Better health;2. Transformed quality of care and delivery; and3. Sustainable finances.

We recognise that we have considerable contribution to make towards the emerging STPs in our region, whether directly or indirectly and, understanding our influence upon the health system as a whole, we have embarked upon a period of significant change by developing a new collaborative Trust strategy complete with a new operating model and supporting transition with our RAP. Both ofwhich will contribute positively towards the health system and therefore patients. Our RAP, discussed further within chapter 10, is designed to improve performance in the immediate future and will require securing additional capacity to support and deliver this significant transformation through the new operating model business case. Our proposed new operating model, also discussed within chapter 8, plans to deliver significant savings to the health system and more importantly ensure patients receive the right treatment, in the right place, first time. We will require support in securing additional capacity whilst the Trust re-engineers its model to deliver a new integrated system for urgent and emergency care. Both our RAP and proposed new operating model contribute directly towards the 9 ‘must dos’ within the Five Year Forward View. As mentioned previously, we are in continued consultation and negotiation to secure agreement of additional funding required to deliver both the RAP and a new operating model.

No. National 'must dos' for 2016/17 for every local system Applicable to EEAST

Work stream in progress to address

1Develop a high quality STP which identifies most locally critical milestones for accelerating progress in 2016/17

●RAPOperating model developmentReduction of conveyance

2 Return the system to aggregate financial balance● Operating model development

Workforce planning

3Develop and implement local plans to address sustainability and quality of general practice (inc. workforce issues)


4Get back on track with access standards and ambulance waits (75% of Category A calls within 8 minutes)


5 Improvemenmts of 18 week referral to treatment

6Delivering NHS Constitution 62 day cancer waiting standard and make progress in improving one year survival rates

7Achieve and maintain two new mental health access standards and continue to meet dementia diagnosis rate of 2/3 ofestimated number of people with dementia

8 Deliver actions to transform care for people with learning disabilities

9 Develop and implement an affordable plan to make improvements in quality●

RAPOperating model developmentReduction of conveyance


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9.3 Specific Examples of how we are contributing towards the STP

We can also cite other more specific examples of innovative work plans we are developing which will benefit the system as a whole including:

Participation within the Cambridgeshire and Peterborough UEC Vanguard: The Vanguard aims to accelerate improvements and develop a best practice model which helps address variations in access to services and health inequalities in the region. Together we will be focusing on:

Promoting self-care and management Helping people with urgent care needs get the right advice first time and access the right

service 7 days a week. Providing highly responsive urgent care services outside of hospital. Developing a workforce to meet these needs including GP Fellows, Advanced Nurse

Practitioner and advanced AHP roles, developed community pharmacist roles, physician’s assistants and staff equipped to meet mental and physical health needs.

Reassessing service standards based on outcomes and redefine payment methods to incentivise system redesign.

Establishing Urgent Care Clinical Hubs (aligned to our overall strategy of developing a new operating model; in its early stages but when complete we hope to see a region wide benefit to Commissioners, Acute and Community Trusts);

Improving access to community health & social care rapid response and falls services. (Single Point of Access pathway referral systems in place. We have recruited to the Hear and Treat Team, increasing referrals to alternatives to ED, such as falls teams, rapid response and referral team across the region);

Increasing direct referral to components of the Urgent and Emergency Care Network (local CQUIN is focusing on providing crews with GP support to help make appropriate conveyance decisions. Allied to this is the use of all 19 local Directory of Service systems to facilitate use of alternative care pathways); and

Enhanced working with community mental health teams (new referral pathways trialed last year and agreed as a region wide pilot to ensure that the most urgent mental health referrals get a quick response under a RAG traffic light protocol).

9.4 Early View of Vision for Local Health and Care System

The NHS Shared Planning Guidance asked every local health and care system in England to come together to create their own ambitious local plan for accelerating the implementation of the FYFV. These blueprints, called Sustainability and Transformation Plans (STPs), are place-based, multi-year plans built around the needs of local populations. Local Authorities, and other health and care services have come together to form 44 STP ‘footprints’ of which 6 relate to our Trust. These are:

1. Cambridgeshire and Peterborough2. Norfolk and Waveney3. Suffolk and North East Essex4. Milton Keynes, Bedfordshire and Luton5. Hertfordshire and West Essex6. Mid and South Essex

We have assigned each of these footprints, which are of a scale enabling transformative change and the implementation of the Five Year Forward View vision of better health and wellbeing, improved quality of care, and stronger NHS finance and efficiency, to a senior operational manager within our Trust. They are tasked with working with other STP leads to innovate and deliver system change andoffer support through the delivery of our new operating model.


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10. Remedial Action Plan (RAP)

We have developed a RAP to improve our performance against national quality indicators in the immediate term whilst we reengineer our estate to a new operating model. The RAP is underpinned by the recruitment of additional resources to increase our capacity in line with demand (through the use of PAS and agency). Our ability to implement such change is contingent upon:

Securing significant additional funding; and

Recruitment of PAS and agency resources without any agency constraints.

Whilst we are undertaking an extensive recruitment programme, new recruits will need to undertake appropriate training programmes which means that this capacity will not be available in the current year, further emphasising that in order to ensure the Trust work towards national performance standards and provide a safe service to our patients we clearly need to use a combination of agency staff and PAS for the coming year.

10.1 Delivery against National Quality Indicators - Performance Challenges

We continue to be significantly challenged around delivery of Red performance and this challenge is set to continue over the remainder of 2016/17 and beyond, without a considerable shift in the model of care delivery. Within the 2015/16 EEAST Emergency Operations NHS Contract Service Development Improvement Plan, we agreed trajectories for Red performance. As Red 2 performance did not meet the trajectories set by CCGs this triggered the Lead Commissioner to request a Remedial Action Plan (RAP), subsequently R1 and R19 performance have also deteriorated. The RAP was to be developed to indicate when our Trust would deliver against the national performance targets.

We have held joint escalation meetings with the lead CCG, NHSI and NHSE due to the capacity gap that exists to deliver sustainable performance to resolve this (resulting in our RAP).

10.2 Recognition of Performance Challenges and Development of RAP

We are committed to improving the service delivered to our patients. Understanding our influence upon the health system as a whole we have embarked upon a period of significant change by developing a new collaborative Trust strategy complete with a more flexible and integrated new operating model that positively supports the health system and therefore patients. This is awaiting final approval by all stakeholders and investment.

The new operating model plans to deliver significant savings to the health system and more importantly ensure patients receive the right treatment, in the right place, first time. If approved and as agreed through the escalation process, we will require support in securing additional capacity (agency and PAS in the short term) whilst we re-engineer our operating model to deliver a new integrated system for urgent and emergency care. Delivery of a new operating model will itself be underpinned by delivery of the RAP. We will require additional capacity to support this significant transformation and, through the use of additional agency and PAS, we anticipate that delivery against national performance targets will improve whilst transition to the new operating model takes place.

Understanding the continued pressures to deliver national performance standards in 2016/17 with exponential growth in red calls, changes to NHS Ambulance Quality Indicator (AQI) Guidance and hospital delays, our RAP asks commissioners to support a significant but steady improvement in performance which will assist in improving quality whilst at the same time creates the required ‘space’ to re-engineer a new operating model over the next 3 years.

We continue to work with the Commissioners and NHSI to develop an agreed RAP and secure funding which will provide us with the ability to improve performance against national targets as we look to transition towards a new operating model.

An agency cap of £3m has also been imposed upon us by the NHSI which we are looking to increase.


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10.3 Performance Improvement Trajectories - General

With support from a third party consultancy we have modelled future capacity requirements against future demand and have forecast our performance trajectory assuming that we are successful in securing additional funding for our RAP.

Projections are based upon granular analysis of past and current trends and take a prudent view of future performance improvements which are anticipated to be delivered as a result of securing additional capacity against increasing demand.

Projections assume overall regional growth of 3% in line with current planning although acknowledgement is made of a higher growth rate within Red demand calls as we have seen in the recent past.

We have also made system-centric assumptions that CCGs will deliver improvement trajectories which reduce hospital handover delays (committed to in 2015/16) and bringing down 111 to 999 conversion rates down to national average (by end of Q3) and that there will be no pathway changes instigated which impact upon job cycle times adversely thus potentially reducing our ability to deliver our own performance improvement.

Assuming that the above is achieved then we project an improvement in R1 and R2 (8 and19) performance to meet national targets by March 2017.

Performance Improvement – Tail Breaches

We have found a broad correlation between PAS expenditure (i.e. additional capacity) and R2 tails and so we are expecting a significant decrease in R2 tails with the acquisition of additional resource, should funding be secured.

ConclusionEEAST are proud of the standard of clinical care which we deliver to patients but acknowledge that we must improve delivery against national response time targets and believe there is a lot more we can offer to the system and urgent and emergency care patients. Medium term, we are seeking to do this through a transition to a new operating model with an integrated clinical hub the benefits of which will contribute significantly towards the emerging STP. Short term we will need support from the Commissioners to allow us to increase our capacity to meet ever increasing demand. We are excited at the opportunities with which we may capitalise upon to benefit patients and underpin financial recovery of the wider health system. Whilst our financial plan for 2016/17 meets the stretched NHSItarget of a surplus of £1.5m, our ability to deliver improved sustainable performance and a new operating model is contingent upon significant funding, not included within this financial plan, and to this end we continue to work with our Commissioners and NHSI to an agreed way forward that secures our sustainable future.


Glossary

Abbreviation Term

ACQI Ambulance Clinical Quality Indicators

BAF Board Assurance Framework

CAD Computer Assisted Dispatch

CCG Clinical Commissioning Group

CQC Care Quality Commission

CQSG Clinical Quality Steering Group

CQUIN Care Quality and Innovation

ECA Emergency Care Assistant

ED Emergency Department

ELB Executive Leadership Board

EMT Emergency Medical TechnicianFYFV Five Year Forward View

HART Hazardous Area Response Team

NHS National Health Service

NHSE NHS England

NHSI NHS Improvements (formerly Trust Development Authority)

PAS Private Ambulance Service

PTS Patient Transport Service

RAP Remedial Action Plan

ROSC Return of Spontaneous Circulation

SAP Student Advanced Paramedic

STF Strategic Transformation Funding

STP Strategic Transformation Programme

UECN Urgent and Emergency Care Network

operational plan 2016/17 - welcome to eeast operating plan 2016-17.… · operational plan 2016/17...

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